SECTION 317:35-17-5. ADvantage program medical eligibility determination

  The Oklahoma Department of Human Services (DHS) area nurse or nurse designee, makes the medical eligibility determination utilizing professional judgment, the Uniform Comprehensive Assessment Tool (UCAT) Parts I and III, and other medical information.

(1)   When ADvantage care services are requested or the UCAT I is received in the county office, the:

(A)   DHS nurse is responsible for completing the UCAT III; and

(B)   social service specialist is responsible for contacting the applicant within three business days to initiate the financial eligibility application process.

(2)   Categorical relationship must be established for determination of eligibility for ADvantage services. When a categorical relationship to disability was not established, the local social service specialist submits the same information per Oklahoma Administrative Code (OAC) 317:35-5-4(2) to the Level of Care Evaluation Unit (LOCEU) to request a determination of eligibility for categorical relationship. LOCEU renders a decision on the categorical relationship to the person with the disability using the Social Security Administration (SSA) definition. A follow-up is required by the DHS social service specialist with SSA to ensure the disability decision agrees with the LOCEU decision.

(3)   Community agencies complete the UCAT I, and forward the form to the county office. When the UCAT I indicates the applicant does not qualify for Medicaid long-term care services, the applicant is referred to appropriate community resources. Members may call the care line at 1-800-435-4711.

(4)   The DHS nurse completes the UCAT III assessment visit with the member within 10-business days of receipt of the referral for ADvantage services for an applicant who is Medicaid eligible at the time of the request. The DHS nurse completes the UCAT III assessment visit within 20-business days of the date the Medicaid application is completed for new applicants.

(5)   During the UCAT III assessment visit, the DHS nurse informs the applicant of medical eligibility criteria and provides information about the different long-term care service options. When there are multiple household members applying for the ADvantage program, the UCAT assessment is done for them during the same visit. The DHS nurse documents whether the member chooses nursing facility program services or ADvantage program services and makes a level of care and service program recommendation.

(6)   The DHS nurse informs the member and family of agencies certified to deliver ADvantage case management and in-home care services in the local area to obtain the applicant's primary and secondary informed choices, ensuring adherence to conflict free case management requirements.

(A)   Providers of ADvantage services for the member, or for those who have an interest in, or are employed by an ADvantage provider for the member must not provide case management or develop the person-centered service plan, except when the ADvantage Administration (AA) demonstrates the only willing and qualified entity to provide case management and/or develop person-centered service plans in a geographic area, also provides other ADvantage services.

(B)   When the member and/or family declines to make a provider choice, the DHS nurse documents the decision on Form 02CB001, Member Consents and Rights.

(C)   The AA uses a rotating system to select an agency for the member from a list of all local, certified case management and in-home care agencies, ensuring adherence to conflict free case management requirements.

(7)   The DHS nurse documents the names of the chosen agencies and the agreement of the member, by dated signature, to receive services provided by the agencies.

(8)   When the member's needs require an immediate interdisciplinary team (IDT) meeting with home health agency nurse participation to develop a person-centered service plan, the DHS nurse documents the need for priority processing.

(9)   The DHS nurse scores the UCAT III. The DHS nurse forwards the UCAT III and documentation of financial eligibility, documentation of the member's case management and in-home care agency choices to the area nurse or nurse designee for medical eligibility determination.

(10)   When based upon the information obtained during the assessment, the DHS nurse determines the member may be at risk for health and safety, DHS Adult Protective Services staff is notified immediately and the referral is documented on the UCAT.

(11)   Within 10-business days of receipt of a complete ADvantage application, the area nurse or nurse designee determines medical eligibility using nursing facility level of care criteria and service eligibility criteria per OAC 317:35-17-2 and 317:35-17-3 and enters the medical decision on the system.

(12)   Upon notification of financial eligibility from the social service specialist, medical eligibility, and approval for ADvantage entry from the area nurse or nurse designee, the AA communicates with the case management provider to begin care and service plan development. The AA communicates to the case management provider, the member's name, address, case number, Social Security number, number of units of case management and the number of units of home care agency nurse evaluation authorized for service plan development. When the member requires an immediate home visit to develop a person-centered within 24 hours, the AA contacts the case management provider directly to confirm availability and electronically sends the new case packet information to the case management provider.

(13)   When the services must be in place to ensure the health and safety of the member upon discharge to the home from the nursing facility or hospital, a case manager from an ADvantage case management provider selected by the member and referred by the AA follows the ADvantage institution transition, case management procedures for care, and service plan development and implementation.

(14)   A new medical level of care determination is required when a member requests any changes in service program, from:

(A)   State Plan Personal Care to ADvantage services;

(B)   ADvantage to State Plan Personal Care services;

(C)   nursing facility to ADvantage services; or

(D)   ADvantage to nursing facility services.

(15)   A new medical level of care determination is not required when a member requests re-activation of ADvantage services after a short-term stay of 90-calendar days or less in a nursing facility when the member had previous ADvantage services and the ADvantage certification period has not expired.

(16)   When a UCAT assessment was completed more than 90-calendar days prior to submission to the area nurse or nurse designee for a medical decision, a new assessment is required.

[Source: Added at 12 Ok Reg 753, eff 1-6-95 through 7-14-95 (emergency); Added at 12 Ok Reg 3133, eff 7-27-95; Amended at 14 Ok Reg 56, eff 4-30-96 (emergency); Amended at 14 Ok Reg 1802, eff 5-27-97; Amended at 15 Ok Reg 3715, eff 5-18-98 (emergency); Amended at 16 Ok Reg 1438, eff 5-27-99; Amended at 17 Ok Reg 2410, eff 6-26-00; Amended at 18 Ok Reg 2969, eff 5-17-01; Amended at 19 Ok Reg 1071, eff 5-13-02; Amended at 20 Ok Reg 1958, eff 6-26-03; Amended at 21 Ok Reg 2252, eff 6-25-04; Amended at 29 Ok Reg 1172, eff 6-25-12; Amended at 33 Ok Reg 379, eff 1-13-16 (emergency); Amended at 33 Ok Reg 909, eff 9-1-16; Amended at 34 Ok Reg 726, eff 9-1-17]